Abstract

Introduction

Ultrasound-guided (UG) technique is the recommended procedure for central venous catheterization
(CVC). However, as ultrasound may not be available in emergency situations, guidelines
also propose that physicians remain skilled in landmark (LM) placement. We conducted
this prospective observational study to determine the learning curve of the LM technique
in residents only learning the UG technique.

Methods

During the first three months of their rotation in our ICU, residents inexperienced
in CVC used only the real-time UG technique. During the following three months, residents
were allowed to place CVC by means of the LM technique when authorized by the attending
physician.

Results

A total of 172 procedures (84 UG and 88 LM) were performed by the inexperienced residents
during the study. The success rate was lower (72% versus 84%; P = 0.05) and the complication rate was higher (22% versus 10%; P = 0.04) for LM compared to UG procedures. Comparison between the five last UG procedures
and the first five LM procedures performed demonstrated that the transition between
the two techniques was associated with a marked decrease of the success rate (65%
versus 93%; P = 0.01) and an increase of the complication rate (33% versus 8%; P = 0.01). After 10 LM procedures, residents achieved a success rate and a complication
rate of 81% and 6%, respectively.

Conclusions

Residents who only learn the UG technique will not be immediately able to perform
the LM technique, but require specific training based on at least 10 LM procedures.
The question of whether or not the LM technique should still be taught when an ultrasound
device is not available must therefore be addressed.